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Aniemeke et al.
for high-risk patients. The authors projected that this decrease
in readmission rates could result in an annual cost savings of
more than $780 000. Medication education helps prevent
adverse drug events, promotes medication adherence, and
encourages appropriate medication use.5
Recent data indicate that nearly 20% of patients discharged
from the hospital experience a preventable adverse event
within 3 weeks from discharge.6 The majority of these adverse
events are considered to be medication related.6 With this
compelling evidence in mind, strategically positioning a clinical pharmacist in the discharge process to help identify and
prevent medication-related problems has the potential to
improve medication use, patient outcomes, and quality of care.
The aim of this project was to evaluate the impact of a
discharge medication counseling service on 3-day and
30-day readmission rates, ED visits, and days to first readmission or ED visits in patients deemed high risk for readmission at an academic medical center. To our knowledge,
this is the first study to evaluate 3-day readmit rates and
number of days from discharge to readmission or ED visit.
These endpoints were included in addition to the more commonly studied 30-day readmission rates for quality assurance purposes based on prior reports of unacceptably high
3-day readmission rates and to more specifically measure the
short-term impact of the pharmacist counseling services on
overall adherence to discharge instructions.

Methods
A single-center retrospective review was conducted on adult
patients admitted to a 76-bed general medicine unit at a large
academic medical center from October to December 2014.
Approval from the University of Texas Health Science Center
at San Antonio Institutional Review Board was obtained.
Patients aged 18 years and older, admitted to the adult
medicine service, and classified as being at high risk for hospital readmission within 30 days were included in the study.
Patients were identified as high risk for readmission using a
risk stratification tool called PIECES.7 This software system
is a prioritization tool that was previously validated as a predictor of a patient's 30-day readmission risk. It calculates a
risk score based on multiple factors, including diagnoses for
chronic diseases, evidence of control of these diseases, lab
results, social determinants of health, and so on. The risk
assessment is integrated into the electronic medical record to
allow providers quick and easy access to risk scores based on
information already entered into the record. The cutoff of
48.3% likelihood of being readmitted within 30 days was
classified as high risk at our institution based on the initial
customized thresholds set by the team spearheading the risk
stratification initiative.
Patients who were incarcerated, pregnant, deceased, or
left the hospital against medical advice were excluded from
the study. Given the retrospective nature of this study,
patients who received counseling were not consented.

The pharmacy department implemented a consult-based
pharmacy discharge counseling service for high-risk patients on
the adult general medicine unit in October 2014. Upon implementation, providers on the general medicine service were educated on the availability of the clinical pharmacy consult service
by means of distributed flyers as well as real-time reminders by
pharmacists. Physicians initiated consults on patients who met
criteria for being at high risk for readmission.
Upon receipt of a consult order, a clinical pharmacist performed discharge medication reconciliation to ensure appropriateness of therapy, evaluate drug allergies, and identify
and request clarification on duplicate or unnecessary therapy.
Patients were counseled on medication names, indications,
mechanisms of action, directions for use, administration
techniques/routes, potential drug/food interactions, side
effects, and monitoring if needed. The pharmacist then
assessed the effectiveness of the education provided by utilizing teach-back or show-back methods or by having the
patient verbalize instructions. Patients received verbal and
written education using Micromedex Carenotes and institution-specific medication brochures when available.
Counseling was completing between 8:00 a.m. and 5:00
p.m., Monday through Friday. Patients who received discharge counseling through the consult service were identified retrospectively for data collection using an internal
computerized pharmacy consult report.
The primary outcome of this analysis was to compare the
effect of the discharge medication education on 3-day and
30-day readmission rates in high-risk patients who received
counseling (study group) compared with high-risk patients
admitted to the same unit during the same time period who
did not receive counseling (control group). Secondary outcomes were to evaluate effects of the discharge medication
education on 3-day and 30-day ED visits and the number of
days to first readmission or ED visit between both groups.

Statistical Analysis
Data were analyzed using JMP 11.0.0 (SAS Institute, Cary,
North Carolina). Continuous variables were tested for normality using the Shapiro-Wilk W test. Normally distributed
continuous data were analyzed using the Student t test, and
nonnormally distributed continuous data were analyzed
using the Wilcoxon rank sum test. The chi-square or Fisher
exact test was used to compare nominal data, as appropriate.
An a priori alpha level of ≤.05 was used to determine statistical significance for all comparisons.

Results
During the 3-month study period, 44 high-risk patients
received discharge medication counseling (study group).
Forty-five high-risk patients who did not receive counseling
were randomly selected to serve as the control group, for a
total inclusion of 89 patients in this study. Most of the

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